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Surgeon’s report October 2016 Lira

Report Lira October 2016 Judy Mella

Antoinette has given a very good background account

One of the best moments was being recognised so warmly by the students I taught last year.
There were visible changes at the university – the hospital is now under construction and the foundations and ground floor in place. Upstairs in the health sciences block the “spare room “ has been made into a skills lab with resuscitation mannequins, mama Natalie, simulation kit , books etc The computers previously there have been moved to a computer lab in the admin block.

Female surgical ward

This ward has 42 beds, and includes female paediatric surgical patients. During September there were 65 admissions with an average stay of 15 days. The ward is clean and the rounds well organised. However there are several areas to work on:

1.There seems no understanding of the importance of elevation – either legs with distal cellulitis or hands with burns/wounds/fractures. I did a teaching session on this and provided them with coated foam banding for collar and cuffs.

2.There is also a lack of understand about immobilisation. Two patients on the wards who were immobilised had developed catastrophic bedsores during their admission. They did have a turning “chart” but were being turned less than once a day. Many of the patients are anaemic/chronically infected/malnourished when they present and are extremely high risk. I have had a long talk with sister about this and suggested that we get foam wedges for these patients to tilt them and I will design a chart to go above the patients bed with a clock face to document 2 hourly turning. This will need to wait until the next visit. There is no visible evidence that these patients are being helped to mobilise a little with help, as certainly one of them could have got out of bed with support and appropriate abdominal bandaging (she had an entero-cutaneous fistula). There are no chairs to sit on as a mobilisation incentive.

3.Privacy is a problem too – there is a screen available but no space for it between the patient’s beds.

4.I spent a session at least every other day teaching the students clinical skills or on the signs and conditions present. I find the university students more proactive and inquisitive generally than the students from the other nursing institutions. As per most wards there are too many students – anything up to about 16, which is a big group for clinical teaching in an overcrowded ward. I think it would be very helpful for them to have printed sheets/acetates available on the common surgical conditions having on a hook in the nurses station so that they can learn whilst they are hanging around at times. I will try and prepare something for the next visit. Topics covered were:

  • intestinal obstruction
  • wound management – dressings/gunshot/acute vs chronic/dry vs wet
  • osteomyelitis
  • fistulae
  • septic shock and hemorrhagic shock
  • burns
  • suturing
  • bedsores
  • physiotherapy and mobilisation
  • cellulitis
  • tissue response to injury

Another possible development could be a surgical check list along the lines of the one we are piloting for caesarian section ( see below)

Labour ward and theatres

This will have been described by my midwifery colleagues.
From the surgical perspective we designed (we being the anaesthetists and theatre sister, the sister and medical officer on labour ward, myself and Frankie) a theatre check list for patients going for emergency caesarian section. The idea being that this is checked on the ward so patients arrive in theatre preloaded with fluid before they have their spinal, with all the correct kit for the baby plus the newly introduced name bands. These are two strips of tape or plaster with the mother’s name written on them and placed on her upper arm. The theatre staff take one at delivery and put it on the baby. At times there are 2 or 3 post op mothers with babies randomly scattered along the theatre corridor awaiting transfer back to the ward and muddling is inevitable. Theatres are not ready for a full WHO type check list but starting with this check list from ward to theatre with the plan of also using this for the surgical patients is a good starting point in terms of developing a “check list” mentality.
Sadly the principle general surgeon was on annual leave the 2 weeks I was in Lira. The Obs and Gynae surgeons were in full flow though.
I spent time in theatres teaching the students about assisting – how to hand instruments over, how to set up a trolley for a caesarian section, the names and functions of the instruments and how to hold them and use them. I also taught them whilst observing the operations, and brought in a pelvis with anatomical “bits” to teach applied anatomy for caesarian sections and tubal ligations. This is great for small groups – and I repeated this in one of the lectures at the university.
I also ran a suture session in the labour ward using little leather patches stuck on the wall to mimic a perineum. I taught some students then encouraged them to teach each other whilst I monitored them. I have focussed heavily on this, and sometimes they were delighted to be a “teacher`’!

Other hospital based episodes

There was a neonate with intestinal atresia that Peter found in the NICU corridor without any bowel protection. He was given fluids and needed to be transferred to gull. I sincerely hope that this wasn’t delayed in the mistaken belief that there was a surgeon in the hospital available to operate on site instead, but this little one had no abdominal wall and needed ITU. We did demonstrate how to secure the bowel in wet swabs and cling film, but sadly he died within the day. There was another gastriochisis baby a week later and this one was transferred early to the surgical ward after having the bowel wrapped in cling film ( but no IV).

Skills lab

The afore-mentioned pelvis with anatomical “bits” has found a home here. I have discussed with Professor Jasper about developing this – ie a female pelvis with detachable anatomy ( pelvic floor muscles, urogenital triangle, uterus, tube and ovaries, uterine ligaments, blood supply, bladder and ureter) to be used as a teaching aid. He also thinks it would be great to have models of tubal pregnancies. We are going to work on this together.
I taught urethral cathetersiation to a couple of students and left a demonstation kit so they can teach others.
I made 8 sponge kits for practicing suturing second degree perineal tears, and left them in the skills lab. I have demonstrated this to a few students ( about 12) , and left them a youtube video demonstration of this as well as explaining to the tutors. My only problem was running out of sutures after over 150 suturing demonstrations! I have distributed these suture sets so the students can practice this themselves.

Formal teaching at the university

  • communication skills to year 1
  • wound management and infections to year 3
  • pelvic floor anatomy to year 3
  • dealing with wounds and suturing skills workshop to year 2
  • pelvic floor repairs to year 3
  • post partum haemorrhage to year 3

The turn out was very good – generally about 40 -50 students. Though only about 20 for the year 3 wound lecture.

Assisting at Basics course

I was only involved with a half session on obstetric emergencies.

Pathology – this is important!

This is the elephant in the room. The labs are fresh, clean and well equipped for Chemistry/haemaotology/HIV C4 counts/ blood films (malaria and other parasites), and has two microscopes in good working order. The senior technician has a degree in lab technology and said he is trained to process pathological specimens. However they do not have the equipment for paraffin blocking and slicing. If they did they could easily send the slide images via internet to histopathologists for interpretation – either locally or internationally. In fact there is another institution in Uganda which prepares slides of cervical smears and sends the images to south Africa for diagnosis.

To give an example of the negative impact this has on patients: the current tragedy is that patients can have free admission and surgery, (and I think even radiotherapy though I need to confirm this) for breast cancer. However they have to pay for the specimens to go to Kampala for processing or for it to be processed at a private lab for about £20. For many rural Ugandan women this is unaffordable hence they simply turn around and go home. The word is out that there is no point going to the hospital and whilst a few of these women get transferred to either Gulu or Mulago (Kampala) the vast majority cannot afford the journey. Hence breast cancer is being totally neglected. I checked with the hospital medical records and the entry for September 2016 shows no breast cancer or breast lumps seen as either inpatient or outpatient.
One other diagnostic parameter is the Fine Needle Aspiration ( FNA). this needs nothing other than a needle syringe and an air drying slide. For breast cancer diagnosis in the lab there need to be stains ( H&E) but the lab does not have even these.

I want to see if we can consider making the provision of histology processing kit a priority, as the space and expertise are there. I am planning to collect data to help support the DOH in Lira get funding from MOH centrally to sustain this. Certainly this has local medical and political support.

Breast cancer

Breast cancer incidence in Lira district is unknown . As far as the hospital is concerned there is none as they do not treat them. However it is clearly a very serious problem. In general the women only present very late, and on the whole treatment is inaccessible. I have spoken to key people about he problem and there is unanimous agreement that

  • there is a problem,
  • it is totally neglected
  • there is no data
  • data would galvanise action and be a powerful voice.
  • there is no histology.
  • the radiotherapy machines in Gulu and Kampala are currently unserviced and not working – i don’t know what the plan is.So I have liaised with Prof Jasper at the university, Edmond Acheka ( chef officer for womens and child health) in the district health office, Sr Petua at Lira hospital ( senior principal nursing officer and white ribbon alliance lead), Patrick Opio ( surgeon at NGO supported independent hospital) and we are planning some data collection on breast lumps. This is bordering off the limits of the PAL remit and there is a separate report available if anyone wants it.

    General suggestions

    It would be helpful to know the student curriculum. For example I was scheduled to teach the second years suturing, but in fact this would have benefitted the third or fourth years more. Also to know which year group would be at the hospital on which days. This didn’t matter hugely, but for something like suturing which had a limited supply of kit, I sometimes found I was with the students I had already taught at a different place.

    Summary

    This was the most stimulating and rewarding 2 weeks. I think there has been great connection between Poole and Lira which is hugely beneficial to both institutions. I am sure the South Sudanese students will come soon once the funding has been finalised between Uganda and South Sudan.



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